- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,754.23 / $2,951.21
| Professional | | $2,511.89 | $2,754.23 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,760.83 / $8,128.31
| Professional | | $6,025.60 | $6,760.83 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Professional | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,495.41 / $8,128.31
| Professional | | $2,818.38 | $5,495.41 | $8,128.31 |